Why do payers need prior authorization solutions? Because members deserve a better experience.

December 20, 2021

Prior authorization plays an important role in helping patients access safe and effective care. But physicians and health plans agree: the prior authorization process needs to change.

Groups representing both providers and payers came together in 2018, stating that the prior authorization process “can be burdensome for all involved — healthcare providers, health plans and patients.” 

The groups, including the American Medical Association, American Hospital Association, AHIP and the Blue Cross and Blue Shield Association, co-authored a consensus statement with the shared goals of promoting timely access to care, making the prior authorization process more efficient and reducing administrative burdens associated with prior authorization requests. 

But still, prior authorization remains a time-consuming process. In a 2020 American Medical Association survey, 94% of physicians reported prior authorization-related delays in their patients' care. Physicians and their staff also spend an average of two business days each week completing prior authorizations for their patients, balancing electronic prior authorizations, faxes and phone calls, the survey found — which can drive up the cost of care for everyone and delay reimbursement.

Health plans recognize that prior authorization is an important part of ensuring their members receive appropriate care but also recognize room for improvement: A 2019 AHIP survey of health plans found 89% are working to streamline their medical care prior authorization process and workflow. The majority of these health plans (84%) identified automation as the biggest opportunity for improvement.

“No one in healthcare sits there and says, ‘I love the fax machine. This is my favorite way of transmitting clinical documents,’” says Dr. YiDing Yu, practicing physician and chief medical officer at Olive, of the primitive prior authorization process. “We can’t tolerate this inefficiency for our patients — they deserve a lot better.”

How payers can finally achieve frictionless prior authorization

Technological advances now allow artificial intelligence to automate the entire prior authorization process, connecting payers and providers for a more streamlined, frictionless experience that can speed up patient care and improve member satisfaction.

Olive’s Utilization Management solution takes a proven three-pronged approach to reducing prior authorization friction:

  • Automated approvals and denials. Olive automatically reviews incoming authorization requests from providers and delivers recommendations to health plan staff when submissions have sufficient clinical documentation and satisfy authorization requirements.
  • Payer Approval Guidelines Loop. Working as an AI sidekick, Olive enables AI- assisted clinical reviews, providing the health plan reviewer with the relevant payer medical necessity rules, improving staff efficiency.
  • Point-of-care authorization. Olive can automate prior authorizations on both sides of the fax machine, connecting payers and health system providers like never before and delivering real-time decisions at the point of care.

Olive’s Utilization Management solution increases payers’ control over their medical spend while also realizing administrative efficiency, improving the provider experience and accelerating members’ access to care. Learn more about how Olive’s precision Utilization Management solution has solved industry challenges related to prior auth approvals for both payers and providers.